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Published on: April 7, 2021
Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial
Judith Ju Ming Wong1,2, Hongxing Dang3,4, Chin Seng Gan5
1Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.
Insights
Lung-protective mechanical ventilation (LPMV) adherence in pediatric acute respiratory distress syndrome (PARDS) is crucial. While an LPMV protocol didn't directly reduce mortality, adherence to its key elements significantly lowered the risk of death in PARDS patients.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Lung-protective mechanical ventilation (LPMV) is recommended for pediatric acute respiratory distress syndrome (PARDS) but lacks robust data and shows variable adherence.
- Clinical practice often deviates from recommended LPMV strategies, potentially impacting patient outcomes.
Purpose of the Study:
- To evaluate the impact of an LPMV protocol versus standard care on mortality in pediatric patients with PARDS.
- To assess the association between adherence to specific LPMV elements and mortality in PARDS.
Main Methods:
- A multicenter prospective before-and-after study was conducted across 21 pediatric intensive care units (PICUs).
- Patients meeting the Pediatric Acute Lung Injury Consensus Conference 2015 criteria for PARDS and requiring invasive mechanical ventilation were included.
- The LPMV protocol incorporated limits on peak inspiratory pressure (PIP), driving pressure (DP), tidal volume, PEEP/FiO2 combinations, permissive hypercarbia, and conservative oxygen targets.
Main Results:
- No significant difference in 60-day mortality was observed between the LPMV protocol group (22.8%) and the non-LPMV group (28.3%).
- Adherence to the LPMV protocol significantly improved in the LPMV group compared to the non-LPMV group (57.1 vs. 47.6).
- After adjusting for confounders, higher adherence to LPMV strategies was associated with a reduced risk of 60-day mortality (aHR, 0.98; P = 0.004), particularly adherence to PIP, DP, and PEEP/FiO2 settings.
Conclusions:
- Adherence to specific lung-protective mechanical ventilation elements during the initial week of PARDS is linked to decreased mortality.
- While the LPMV protocol itself did not show a direct mortality benefit, improved implementation and adherence to its components are critical for better patient outcomes.
- Further research and strategies are needed to enhance the implementation and adherence to LPMV in clinical practice for PARDS management.
Objectives:
Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS.
Design:
Multicenter prospective before-and-after comparison design study.
Setting:
Twenty-one PICUs.
Patients:
Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation.
Interventions:
The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to F io2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets.
Measurements And Main Results:
There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/F io2 combinations were associated with reduced mortality.
Conclusions:
Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
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